It will take a major effort by state officials, health providers and advocates to improve coordination and delivery of healthcare in some of the state’s most economically challenged communities, health leaders said yesterday.
But if that effort is successful, it could have implications for the entire country, according to participants in a conference attended by about 160 healthcare experts.
The conference focused on the launch of Medicaid accountable care organizations (ACOs) next year. In ACOs, healthcare providers are paid based on patient outcomes and their record of keeping costs down rather than for each service they provide.
“The service delivery models inside specialty care and primary care need to be completely and totally revamped,” said Dr. Jeffrey Brenner, founder and executive director of the Camden Coalition of Healthcare Providers. “When we’re done, they won’t look anything like they do now.”
Brenner, who has become nationally prominent for his efforts to improve healthcare coordination, said state government has a big role to play in reforming the healthcare delivery system, including aligning the criteria and coordination of different programs, eliminating unnecessary barriers and making health claims data publicly available.
“We’re going to have to choose as a state whether we’re going to fix this,” Brenner said.
Brenner started his work in Camden in a since-shuttered primary care practice, but built the coalition through the use of careful analysis of patient data and funding from public and private sources, including the Nicholson Foundation, which also sponsored the event yesterday. The Affiliated Accountable Care Organizations, an initiative of the New Jersey Health Care Quality Institute, held the conference in Plainsboro.
Nicholson Foundation Deputy Director Joan Randell noted that New Jersey is ranked 48th in the country in both healthcare costs and avoidable hospital use.
“Like the rest of the nation’s healthcare delivery system, New Jersey’s is broken,” she said.
While groups like Brenner’s were early national leaders in inspiring similar efforts in other states, those states are now beginning to supersede New Jersey, Randell said. While the state is launching a pilot ACO program, the 2011 law that created the program didn’t provide public funding for it.
“These states are now providing substantial public resources to develop their versions of ACOs,” including funds to compensate providers for reduced spending known as “gain sharing,” Randell said. “They built on New Jersey’s ideas, but have now begun to move ahead of New Jersey, that state that gave birth to these ideas. It is time to lead once again.”
Rob Houston, a program officer with the Hamilton-based Center for Health Care Strategies, noted that there will be several challenges for the 13 communities that could launch ACOs under the three-year pilot program.
They include building well-qualified governing boards, having the capacity to gather and analyze data, being able to measure whether patients’ health quality improved.
Houston co-wrote a report that provides tools for communities that plan to build ACOs His organization will host a webinar on the topic on July 12.
Report coauthor Bruce Dees, principal of the healthcare consulting firm Applied Health Strategies, expressed concern about another potential roadblock to communities that want to host Medicaid ACOs – proposed state regulations that would make it difficult for communities that aren’t ready to launch ACOs early next year to apply later in the three-year pilot program.
Another key to making the Medicaid ACOs work is the active participation of the insurance companies that manage Medicaid in the state. United HealthCare is planning to expand its participation in an ACO-style approach in Camden, and conference participants expressed hope that other insurers would follow suit.
New Jersey Health Care Quality Institute President and CEO David Knowlton said that one challenge in building successful ACOs is designing strong incentives for achieving the desired outcomes.
“There is no question that the ACO could be a wonderful opportunity in collaborating hospitals and the delivery system,” Knowlton said. “It could also harm hospitals. If those incentives are not properly aligned, it won’t work.”
Brenner said that building a model of healthcare focused on careful use of data and a team-based approach requires that the model in place for the past century must be revamped. He said healthcare providers can learn from other businesses that constantly reassess their approach.
Brenner noted that patients at one provider could have as many as 19 different charts because each specialist treating a patient could create a separate chart. He advocates centralizing patient care in “medical homes,” based on a coordinated team.
“We are underestimating how big of a problem we have to solve,” Brenner said. “We are under-spending in our medical home efforts.”
Brenner discussed these issues along with his counterparts involved with similar care coordination efforts to form Medicaid ACOs — Trenton Health Team Executive Director Dr. Ruth Perry and Greater Newark Health Care Coalition project director Michael Anne Kyle.
Perry said she envisions the Medicaid ACO effort leading to a broader redesign of other social services that relate to health, such as housing programs. Kyle noted the challenge in coordinating care across the wide range of institutions in Newark.
Brenner added that every primary-care office needs to be able to track all of its patients’ interactions with the complex healthcare system in order to be accountable in managing their care.
“We have a lot of spaghetti to untangle in the state,” Brenner said of this complexity.
The discussion turned toward how these efforts will be affected by the Medicaid eligibility expansion set for January 1. Perry expressed concern about how the many people who will have insurance for the first time will receive primary care.
“It’s something that we’re working through, but don’t have a clear answer yet,” she said.
Brenner said providers must prepare for the “surge” in patients signing up for healthcare when Medicaid and a health insurance marketplace launch in October.
He pointed to two potential steps the state could take to make the provision of care easier as demand increases. One would be to move every aspect of Medicaid patient care, including behavioral healthcare, into a single managed-care system. Another step would be to increase the transparency of health data, including insurance claims. The Christie administration recently decided against pursuing federal funding to launch an all-payer health claims database.
“Camden has more data than any other city – that shouldn’t be true,” Brenner said of the data-sharing that his coalition has fostered.